Profile of Patients Receiving CT scans for Mild Traumatic Brain Injury in a Tertiary Care Hospital in Ethiopia.

BACKGROUND: Traumatic brain injury (TBI) is a leading contributor to emergency department (ED) mortalities in Ethiopia. Mild TBI patients comprise half of all TBI patients presenting for care in Ethiopia and have a high potential for recovery. As such, context-specific care-improving strategies may be highly impactful for this group of patients. OBJECTIVE: This study examines the presentation and disposition of mTBI patients who received a computed tomography scan of the head (CTH) upon arrival at the largest teaching hospital in Ethiopia. METHODS: A retrospective cohort study was conducted from 2018-2021 including patients >13 years old with a head injury and a Glasgow Coma Score of 13-15 who obtained a computed tomography scan of the head (CTH). Variables were collected from medical charts and single and multi-variable analyses assessed outcomes of clinically important TBI (ciTBI) requiring a neurosurgical procedure or admission. RESULTS: A total of 193 patients were included. They were predominantly young men with no comorbidities, injured in road traffic accidents or by assault, had stable vital signs and were treated in lower-acuity ED areas. A minority demonstrated focal deficits, and 29.5% of patients had ciTBI. Most patients were discharged from the ED, but 13% were taken for operative neurosurgical procedures and 10.4% were admitted to the neurosurgery ward for observation. ED stays ranged from 8 hours to 10 days, as patients waited for CT availability, neurosurgical decision, or transportation. Female sex was independently protective of ciTBI. Self-referral status was independently protective against operative intervention. Female sex and self-referral status were independently protective of a disposition of admission and/or going to the operating room. CONCLUSION: This study characterizes the mTBI subgroup of head injury patients in Ethiopia's busiest ED: predominantly healthy young men with low-acuity presentations and only a fraction with abnormal neurological examinations. Nonetheless, about one-third had clinically important TBI and a minority were taken for neurosurgical procedures or admission, with female sex and self-referral identified as protective factors. Meanwhile, many patients stayed in the ED for days due to social or other non-medical reasons. As TBI care in Ethiopia continues to improve, optimizing care for the mTBI subgroup is tantamount given their high recovery potential. This care will benefit from efficiently identifying those who need intervention or hospital level of care, and discharging those who do not.

Risk Factors for Neural-Tube Defects Detected in Utero: A Prospective Community-Based Study from Addis Ababa.

BACKGROUND: A recent community-based study from Addis Ababa identifying Neural Tube Defect (NTD) cases by ultrasound examination of pregnant women showed a higher prevalence of 17 per 1000 fetuses. The risk factors behind the high prevalence remain unclear. METHODS: Altogether 891 of the 958 women participated in the ultrasound examination. Thirteen with unaffected twin pregnancies were excluded. Among 878 singleton pregnancies, 15 NTD cases were identified. Serum Folate, vitamin B12, and homocysteine levels were measured in case-mothers and a sub-set of 28 noncase mothers. Because of the modest sample size, exact logistic regression analysis was used to estimate associations between risk factors and NTDs. RESULTS: Serum vitamin status was generally poor for participants in the study. Still, relatively higher values of folate or vitamin B12 in serum, appeared to be protective for NTD (odds ratio [OR] = 0.61 per ng/ml, 95% Confidence interval [CI]: 0.42-0.85 and OR = 0.67 per 100 pg/ml, 95% CI: 0.41-1.02, respectively). High serum homocysteine was associated with higher risk of NTD (OR = 1.3 per µmol/l, 95% CI: 1.02-1.8). Women aged 30 years or more had an OR of 3.5 (95% CI: 1.1-12) for having a NTD child, and families with NTD children had lower household income. Women in the NTD group also had more spontaneous abortions or stillbirths in previous pregnancies. Self-reported intake of folate did not appear to protect against NTDs. CONCLUSIONS: Within this high-prevalence community, poor vitamin status was identified as a risk factor for NTDs detected at ultrasound examination. Improving food security and fortification of foods or food ingredients could be alternative measures.

Perioperative Care and Outcomes of Patients with Brain Tumors Undergoing Elective Craniotomy: Experience from an Ethiopian Tertiary-Care Hospital.

OBJECTIVE: To describe patients, perioperative care, and outcomes undergoing supratentorial and infratentorial craniotomy for brain tumor resection in a tertiary-care hospital in Ethiopia. METHODS: A retrospective cohort study of patients consecutively admitted between January 1, 2021, and December 31, 2021, was performed. We characterized patients, perioperative care, and outcomes. RESULTS: The final sample comprised 153 patients; 144 (94%) were 18 years and over, females (n = 48, 55%) with primarily American Society of Anesthesiologists physical class II (n = 97, 63.4%) who underwent supratentorial (n = 114, 75%), or infratentorial (n = 39, 25%) tumor resection. Patients were routinely admitted (95%) to floor/wards before craniotomy; Inhaled anesthetic (isoflurane 88%/halothane 12%) was used for maintenance of general anesthesia. Propofol (n = 93, 61%), mannitol (n = 73, 48%), and cerebrospinal fluid drain (n = 28, 18%), were used to facilitate intraoperative brain relaxation, while the use of hyperventilation was rare (n = 1). The average estimated blood loss was 1040 ± 727 ml; 37 (24%) patients received tranexamic acid, and 57 (37%) received a blood transfusion. Factors associated with extubation were a) infratentorial tumor location: relative risk (RR) 0.45 (95% confidence interval [CI] 0.29-0.69), preoperative hydrocephalus: RR 0.51, (95% CI 0.34-0.79), shorter total anesthesia duration: 277.8 + 8.8 versus 426.77 + 13.1 minutes, P < 0.0001, lower estimated blood loss: 897 + 68 ml versus 1361.7 + 100 ml, P = 0.0002, and cerebrospinal fluid drainage to facilitate brain relaxation: RR 0.52, 95% CI 0.32-0.84). Approximately one in ten patients experienced postoperative obstructive hydrocephalus, surgical site infections, or pneumonia. CONCLUSIONS: These findings suggest that certain factors may impact patient outcomes following craniotomy for tumor resection. By identifying these factors, health care providers may be better equipped to develop individualized treatment plans and improve patient outcomes. Additionally, the study highlights the importance of postoperative monitoring and management to prevent complications.

Consensus-Based Development of a Global Registry for Traumatic Brain Injury: Establishment, Protocol, and Implementation.

BACKGROUND AND OBJECTIVES: Global disparity exists in the demographics, pathology, management, and outcomes of surgically treated traumatic brain injury (TBI). However, the factors underlying these differences, including intervention effectiveness, remain unclear. Establishing a more accurate global picture of the burden of TBI represents a challenging task requiring systematic and ongoing data collection of patients with TBI across all management modalities. The objective of this study was to establish a global registry that would enable local service benchmarking against a global standard, identification of unmet need in TBI management, and its evidence-based prioritization in policymaking. METHODS: The registry was developed in an iterative consensus-based manner by a panel of neurotrauma professionals. Proposed registry objectives, structure, and data points were established in 2 international multidisciplinary neurotrauma meetings, after which a survey consisting of the same data points was circulated within the global neurotrauma community. The survey results were disseminated in a final meeting to reach a consensus on the most pertinent registry variables. RESULTS: A total of 156 professionals from 53 countries, including both high-income countries and low- and middle-income countries, responded to the survey. The final consensus-based registry includes patients with TBI who required neurosurgical admission, a neurosurgical procedure, or a critical care admission. The data set comprised clinically pertinent information on demographics, injury characteristics, imaging, treatments, and short-term outcomes. Based on the consensus, the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry was established. CONCLUSION: The GEO-TBI registry will enable high-quality data collection, clinical auditing, and research activity, and it is supported by the World Federation of Neurosurgical Societies and the National Institute of Health Research Global Health Program. The GEO-TBI registry ( https://geotbi.org ) is now open for participant site recruitment. Any center involved in TBI management is welcome to join the collaboration to access the registry.

Surgical treatment outcome of children with neural-tube defect: A prospective cohort study in a high volume center in Addis Ababa, Ethiopia.

Introduction: Prevalence of neural tube defects (NTD) is high thus many children are born with a neural tube defect in Addis Ababa, and surgical closure is a commonly performed procedure at the pediatric neurosurgical specialty center. Research question: The primary aim is to study the outcomes in children undergoing surgical closure of NTDs and to identify risk factors for readmission, complications and mortality. Material and methods: Single-center prospective study of all surgically treated NTDs from April 2019 to May 2020. Results: A total of 228 children, mean age 11 days (median 4) underwent surgery during the study period. There were no in-hospital deaths. Perioperatively 11 (4.8%) children developed wound complications, none of them needed surgery and there was no perioperative mortality. The one-year follow-up rate was 62.7% (143/228) and neurological status remained stable since discharge in all. The readmission and reoperation rates were 38 % and 8 % and risk factors for readmission were hydrocephalus (80%) and open defects (88%). Hydrocephalus (P = 0.05) and younger age (P = 0.02) were identified as risk factors for mortality. The wound-related complication rate was 55% at and was associated with large defects (P = 0.04) and delayed closure due to late hospital presentation (P = 0.01). Discussion and conclusion: The study reveals good perioperative surgical outcome and further need for systematic improvement in treatment and follow-up of NTD patients especially with hydrocephalus. We identified risk factors for wound-related complications, readmission and mortality.

An international, prospective observational study on traumatic brain injury epidemiology study protocol: GEO-TBI: Incidence.

Background: The epidemiology of traumatic brain injury (TBI) is unclear - it is estimated to affect 27-69 million individuals yearly with the bulk of the TBI burden in low-to-middle income countries (LMICs). Research has highlighted significant between-hospital variability in TBI outcomes following emergency surgery, but the overall incidence and epidemiology of TBI remains unclear. To address this need, we established the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry, enabling recording of all TBI cases requiring admission irrespective of surgical treatment. Objective: The GEO-TBI: Incidence study aims to describe TBI epidemiology and outcomes according to development indices, and to highlight best practices to facilitate further comparative research. Design: Multi-centre, international, registry-based, prospective cohort study. Subjects: Any unit managing TBI and participating in the GEO-TBI registry will be eligible to join the study. Each unit will select a 90-day study period. All TBI patients meeting the registry inclusion criteria (neurosurgical/ICU admission or neurosurgical operation) during the selected study period will be included in the GEO-TBI: Incidence. Methods: All units will form a study team, that will gain local approval, identify eligible patients and input data. Data will be collected via the secure registry platform and validated after collection. Identifiers may be collected if required for local utility in accordance with the GEO-TBI protocol. Data: Data related to initial presentation, interventions and short-term outcomes will be collected in line with the GEO-TBI core dataset, developed following consensus from an iterative survey and feedback process. Patient demographics, injury details, timing and nature of interventions and post-injury care will be collected alongside associated complications. The primary outcome measures for the study will be the Glasgow Outcome at Discharge Scale (GODS) and 14-day mortality. Secondary outcome measures will be mortality and extended Glasgow Outcome Scale (GOSE) at the most recent follow-up timepoint.

Traumatic brain injury (TBI) is a significant global health problem, which affects 27­69 million people every year. After-effects of TBI commonly affect the injured individuals for years. Most patients who sustain a TBI are from developing countries. Research has shown that there are differences in patients' recovery after TBI between countries and hospitals. The causes of these differences are unclear and tackling them could improve TBI treatment worldwide. To address this need, we have recently established the Global Epidemiology and Outcomes Following Traumatic Brain Injury (GEO-TBI) registry. The international collaborative registry aims to collect data related to the causes, treatments and outcomes related to TBI patients. This data will hopefully enable future research to elucidate the causes of the recovery differences between hospitals, which could lead to improved patient outcomes. The GEO-TBI: Incidence study collects data from all TBI patients that are admitted to participating hospitals or undergo a neurosurgical operation due to TBI during a 90-day period. This study looks at the patient's recovery at discharge using the Glasgow Outcome at Discharge Scale (GODS), and at the 2-week mortality. In addition, the study also evaluates recovery at the most recent follow-up timepoint. We hope that this information will enhance our understanding on the causes, treatments, and commonness of TBI. The study results will also help local hospitals compare their treatment results to an international standard.

Prevalence of neural tube defects among pregnant women in Addis Ababa: a community-based study using prenatal ultrasound examination.

PURPOSE: The primary aim of this study was to estimate the prevalence of NTDs at ultrasound examination in communities of Addis Ababa and secondarily to provide a description of the dysmorphology of the NTD cases. METHODS: We enrolled 958 pregnant women from 20 randomly selected health centers in Addis Ababa during the period from October 1, 2018, to April 30, 2019. Of these 958 women, 891 had an ultrasound examination after enrollment, with a special focus on NTDs. We estimated the prevalence of NTDs and compared it with previously reported hospital-based birth prevalence estimates from Addis Ababa. RESULTS: Among 891 women, 13 had twin pregnancies. We identified 15 NTD cases among 904 fetuses, corresponding to an ultrasound-based prevalence of 166 per 10,000 (95% CI: 100-274). There were no NTD cases among the 26 twins. Eleven had spina bifida (122 per 10,000, 95% CI: 67-219). Among the 11 fetuses with spina bifida, three had a cervical and one had a thoracolumbar defect while the anatomical site for 7 was not registered. Seven of the 11 spina bifida defects had skin covering, while two of the cervical lesions were uncovered. CONCLUSION: We report a high prevalence of NTDs among pregnancies in communities of Addis Ababa based on screening by ultrasound. The prevalence was higher than in previous hospital-based studies in Addis, and the prevalence of spina bifida was particularly high.

Current Neurosurgical Care in Ethiopia Using the Lens of the Lancet Global Health Commission on High-Quality Health Systems.

BACKGROUND: Neurosurgery is a rapidly developing specialty in Ethiopia. Previous global neurosurgery studies have highlighted the need for synchronizing workforce increase with improving quality, access, and capacity to provide neurosurgical care. OBJECTIVE: To evaluate Ethiopia's neurosurgical system and highlight the critical interventions required for the sustained development of Ethiopian neurosurgery as part of a high-quality health system (HQHS). METHODS: A comprehensive survey was sent to all practicing neurosurgeons. Public databases on Ethiopian census reports and current road infrastructure were used for spatial analysis of neurosurgical access. RESULTS: The survey response rate was 90% (45/50). Most respondents were men (95.6%), aged 30 to 40 years (82%), who worked at national referral hospitals (71%). The reported annual caseload per practicing neurosurgeon was >150 cases for 40% of urban and 20% of rural neurosurgeons. Head and spine neurotrauma and tumors were the most common neurosurgical indications. Computed tomography scanner was the most widely available diagnostic equipment (62%). 76% of respondents indicated the presence of postoperative rehabilitation care at their institutions. Thirteen percent and 27% of the nation lived within a 2-hour and 4-hour driving distance from a neurosurgical center, respectively. CONCLUSION: The results highlight the need for vital improvements in neurosurgical capacity to sustain progress toward HQHS. Promoting sustained development in all components of HQHS can be achieved by diversifying the workforce and training residency candidates committed to practicing in underserved regions. Additional strategies might include establishing a national registry for neurosurgical data and implementing policy changes conducive to improving perihospital care and other health system components.

Surgical treatment and outcome of chronic subdural hematoma: a comparative study between Ethiopia and Norway.

BACKGROUND: Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. Here, we studied differences in demographics, treatment, and outcome for CSDH patients in low-income (Ethiopia) and high-income (Norway) countries and assessed potential outcome determinants. METHODS: We included patients from Addis Ababa University Hospitals (AAUH) and Haukeland University Hospital (HUH) who had surgery for CSDH (2013-2017). Patients were included prospectively in Ethiopia and retrospectively in Norway. RESULTS: We enrolled 314 patients from AAUH and 284 patients from HUH, with a median age of 60 and 75 years, respectively. Trauma history was more common in AAUH (72%) than in HUH patients (64.1%). More patients at HUH (45.1%) used anticoagulants/antiplatelets than at AAUH (3.2%). Comorbidities were more frequent in HUH (77.5%) than in AAUH patients (30.3%). Burr hole craniostomy under local anesthesia and postoperative drainage was the standard treatment in both countries. Postoperative CT scanning was more common at HUH (99.3%) than at AAUH (5.2%). Reoperations were more frequent at HUH (10.9%) than at AAUH (6.1%), and in both countries, mostly due to hematoma recurrence. Medical complications were more common at HUH (6.7%) than at AAUH (1.3%). The 1-year mortality rate at HUH was 7% and at AAUH 3.5%. At the end of follow-up (> 3 years), the Glasgow Outcome Scale Extended (GOSE) score was 8 in 82.9% of AAUH and 46.8% of HUH patients. CONCLUSION: The surgical treatment was similar at AAUH and HUH. The poorer outcome in Norway could largely be explained by age, comorbidity, medication, and complication rates.

Neurosurgery Research Output in Ethiopia: A Scoping Review.

BACKGROUND: Neurosurgery-specific research plays a critical role in improving outcomes in patients with neurosurgical diseases. Despite the high burden of neurosurgical diseases in Ethiopia, little is known about types of neurosurgical research from Ethiopia. The goal of this scoping review is to assess the quantity and types of neurosurgical research published in peer-reviewed journals by authors from Ethiopia. METHODS: PubMed, CINAHL, Embase, and Scopus were searched for Ethiopian neurosurgery literature published from 2001 to 2021. We selected articles based on the following criteria: articles must 1) discuss topics within neurosurgery and 2) focus on clinical practice and/or public health in Ethiopia. We collected data on research originality, study designs, and clinical versus public health research. The frequencies and percentages of categorical variables were reported. All analyses were conducted using Jamovi software. RESULTS: Of the 362 results, 89 neurosurgical research articles were included in the final analysis. Of the 89 articles, case reports/series were most common (28.7%), followed by retrospective cohort (20.7%) and prospective cohort studies (18.4%). There were 8 literature reviews (9.2%) and 1 systematic review and meta-analysis (1.1%). No randomized controlled trial was found. Of all articles, 66 (75.9%) focused on clinical practice, and 21 (23.6%) were related to the public health aspect of neurosurgery. Forty-two articles (48.3%) included authors only from Ethiopia; 37 articles (42.5%) involved collaboration between Ethiopian and authors from another country, and 8 articles (9.2%) did not have Ethiopian authors. CONCLUSIONS: Neurosurgery research from Ethiopia is lacking, despite its high disease burden. Case reports/series and cohort studies remain the mainstay, with few systematic reviews and no randomized controlled trial. International collaboration accounts for approximately half of Ethiopian neurosurgery research output. Further research support and infrastructure should be developed to encourage neurosurgery articles from Ethiopia.

Folate, Vitamin B12, and Homocysteine Levels in Women With Neural Tube Defect-Affected Pregnancy in Addis Ababa, Ethiopia.

Background: Neural tube defects (NTDs) are prevalent congenital defects associated with pre-pregnancy diet with low levels of maternal folate. They are linked to severe morbidity, disability, and mortality, as well as psychological and economic burdens. Objective: The goal of this study was to determine the levels of folate, vitamin B12, and homocysteine in the blood of women who had a pregnancy impacted by NTDs. Subjects and Methods: A hospital-based case-control study was undertaken between September 2019 and August 2020. The study comprised a total of 100 cases and 167 controls. Enzyme-linked immunosorbent assay (ELISA) was used to determine the levels of folate, vitamin B12, and homocysteine in the serum. Results: Only 39% of the cases and 54.5% of control mothers reported periconceptional use of folic acid/multivitamin, which indicated a statistically significant difference (p = 0.014). Logistic regression indicated that periconceptional use of folic acid/multivitamin was associated with NTDs (p = 0.015, OR = 1.873, 95% CI: 1.131-3.101). We found that 57% of the cases and 33.5% of controls, as well as 43% of cases and 20.4% of controls had serum folate and vitamin B12 levels below the cut-off value, respectively. Twenty-seven percent of the cases and 6.6% of controls had hyperhomocysteinemia (HHcy). The median concentrations of folate, vitamin B12, and homocysteine in cases and controls were 4.78 and 8.86 ng/ml; 266.23 and 455 pg/ml; 13.43 and 9.7 µmol/l, respectively. The median concentration of folate (p < 0.001) and vitamin B12 (p < 0.001) were significantly lower in the cases than controls, while the homocysteine concentration (p < 0.001) was significantly lower in the controls than cases. Folate [OR (95% CI) = 1.652 (1.226-2.225; p = 0.001)], vitamin B12 [OR (95% CI) = 1.890 (1.393-2.565; p < 0.001], and homocysteine [OR (95% CI) = 0.191 (0.09-0.405; p < 0.001)] levels were associated with NTDs. Conclusion: Folate and vitamin B12 are deficient in both cases and control mothers. The lower levels of folate and vitamin B12 with an elevated homocysteine level in NTD-affected pregnancy may be an indication that these biochemical variables were risk factors for NTDs. Folate/multivitamin supplementation and/or food fortification should be promoted.

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study.

BACKGROUND: Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development. METHODS: We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation. FINDINGS: Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49). INTERPRETATION: Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices. FUNDING: National Institute for Health Research Global Health Research Group.

Neurosurgery in Ethiopia: A New Chapter and Future Prospects.

BACKGROUND: Inequitable access to surgical care is most conspicuous in low-income countries (LICs), such as Ethiopia, where infectious diseases, malnutrition, and other maladies consume the lion's share of the available health resources. The aim of this article was to provide an update on the current state of neurosurgery in Ethiopia and identify targets for future development of surgical capacity as a universal health coverage component in this East African nation. METHODS: Publicly available data included in this report were gathered from resources published by international organizations. A PubMed search was used for a preliminary bibliometric analysis of scholarly output of neurosurgeons in Ethiopia and other low-income countries. Statistical analysis was used to determine the correlation between the number of neurosurgeons and academic productivity. RESULTS: Neurosurgeon density has increased >20-fold from 0.0022 to 0.045 neurosurgeons per 100,000 population between 2006 and 2020. The increase in neurosurgeons was strongly correlated with an increase in total publications (P < 0.001) and the number of new publications per year (P = 0.003). Despite recent progress, the availability of neuroimaging equipment remains inadequate, with 38 computed tomography scanners and 11 magnetic resonance imaging machines for a population of 112.07 million. The geographic distribution of neurosurgical facilities is limited to 12 urban centers. CONCLUSIONS: Ethiopian neurosurgery exemplifies the profound effect of international partnerships for training local surgeons on progress in low-income countries toward improved neurosurgical capacity. Collaborations that focus on increasing the neurosurgical workforce should synchronize with efforts to enhance the availability of diagnostic and surgical equipment necessary for basic neurosurgical care.

Prospective Study of Surgery for Traumatic Brain Injury in Addis Ababa, Ethiopia: Surgical Procedures, Complications, and Postoperative Outcomes.

BACKGROUND: Traumatic brain injury (TBI) is an important cause of trauma-related mortality and morbidity in Ethiopia. There are significant resource limitations along the entire continuum of care, and little is known about the neurosurgical activity and patient outcomes. METHODS: All surgically treated TBI patients at the 4 teaching hospitals in Addis Ababa, Ethiopia were prospectively registered from October 2012 to December 2016. Data registration included surgical procedures, complications, reoperations, discharge outcomes, and mortality. RESULTS: A total of 1087 patients were included. The most common procedures were elevation of depressed skull fractures (49.5%) and craniotomies (47.9%). Epidural hematoma was the most frequent indication for a craniotomy (74.7%). Most (77.7%) patients were operated within 24 hours of admission. The median hospital stay for depressed skull fracture operations or craniotomies was 4 days. Decompressive craniectomy was only done in 10 patients. Postoperative complications were seen in 17% of patients, and only 3% were reoperated. Cerebrospinal fluid leak was the most common complication (7.9%). The overall mortality was 8.2%. Diagnosis, admission Glasgow Coma Scale (GCS) score, surgical procedure, and complications were significant predictors of discharge GCS score (P < 0.01). Age, admission GCS score, and length of hospital stay were significantly associated with mortality (P ≤ 0.005). CONCLUSIONS: The injury panorama, surgical activity, and outcome are significantly influenced by patient selection due to deficits within both prehospital and hospital care. Still, the neurosurgical services benefit a large number of patients in the greater Addis region and are qualitatively comparable with reports from high-income countries.

Prospective Study of Surgery for Traumatic Brain Injury in Addis Ababa, Ethiopia: Trauma Causes, Injury Types, and Clinical Presentation.

BACKGROUND: Traumatic brain injury (TBI) is a public health problem in Ethiopia. More knowledge about the epidemiology and neurosurgical management of TBI patients is needed to identify possible focus areas for quality improvement and preventive efforts. METHODS: This prospective cross-sectional study (2012-2016) was performed at the 4 teaching hospitals in Addis Ababa, Ethiopia. All surgically treated TBI patients were included, and data on clinical presentation, injury types, and trauma causes were collected. RESULTS: We included 1087 patients (mean age 29 years; 8.7% females; 17.1% <18 years old). Only 15.5% of TBIs were classified as severe (Glasgow Coma Scale score 3-8). Depressed skull fracture (44.9%) and epidural hematoma (39%) were the most frequent injuries. Very few patients had polytrauma (3.1%). Assault was the most common injury mechanism (69.9%) followed by road traffic accidents (15.8%) and falls (8.1%). More than 80% of patients came from within 200 km of the hospitals, but the median time to admission was 24 hours. Most assault victims (80.4%) were injured >50 km from the hospitals, whereas 46% of road traffic accident victims came from the urban area. Delayed admission was associated with higher Glasgow Coma Scale scores and nonsevere TBI (P < 0.01). CONCLUSIONS: The injury panorama, delayed admission, and small number of operations performed for severe TBI are linked to a substantial patient selection bias both before and after hospital admission. Our results also suggest that there should be a geographical framework for tailored guidelines, preventive efforts, and development of prehospital and hospital services.

Four-Year Treatment Outcomes of Children Operated for Neural Tube Defect in Addis Ababa, Ethiopia: A Retrospective Study.

BACKGROUND: Closure of neural tube defects (NTDs) in children is a common neurosurgical procedure in Ethiopia, but we know little about the outcomes. The aim of this study was to study outcomes and to identify predictors of mortality and morbidity of surgically treated NTDs. METHODS: Between July 2013 and August 2014, all patients operated for NTDs were prospectively registered in a database and followed for a minimum of 4 years after the initial surgery. RESULTS: A total of 88 children primary operated for NTD closure in the period between July 2013 to August 2014 were included in the study. The median age at primary NTD closure was 29 days. The commonest site of defect was lumbar (60.2%) followed by lumbosacral (11.4%). There was no perioperative mortality, however, 23 (26.1%) of the children developed wound-related complications including cerebrospinal fluid leak and infection. Preoperative cerebrospinal fluid leakage (P = 0.013) was associated with risk of postoperative complications. We acquired 4-years follow-up data for 61 (69%) of the cases. At 4 years, 25 (41%) of these children had died. Presence of hydrocephalus and reduced motor function were found to be negative predictors for survival. CONCLUSIONS: Overall, the prognosis was poor. The study provides a basis for identifying patients at risk to improve the standard of care.

Prevalence of Ventriculostomy Related Infections and Associated Factors in Low Income Setup.

Background: Ventriculostomy, a lifesaving and emergency procedure, is used to address raised intracranial pressure. In resource limited set-up like Tikur Annbessa Specialized Referral Hospital, properly designed closed system for ventriculostomy is not available; a device made with sterile pediatric nasogastric tube connected to urine bag is used. Methods: Institutional based retrospective cross-sectional study conducted on 93 patients with ventriculostomy from January 1, 2009 to June 30, 2018. Ventriculostomy related infection risk described in descriptive statistics and Binary Logistic Regression analysis. Results: The prevalence rate of Ventriculostomy related infection is 25.8% at Tikur Annbessa Specialized Referral Hospital. Identified risk factors: Ventriculostomy stay for five or more days (AOR=7.676, 95% CI: 1.424, 41.367) and cerbro-spinal fluid leak (AOR=4.592, 95% CI: 1.279, 16.488). Ventriculostomy manipulation showed association on bivariate analysis. K.Pneumoniae (34.6%) and Acinetobacter spp. (30.8%) identified as the main organisms. They were sensitive to combined ceftazidime and vancomycin in 19.2% and meropenem in 42.3%. Based on Tängdén's criteria, 11.8% of patients died of Ventriculostomy related infection while 43% of the patients died in total. Mortality from Ventriculostomy related infection is 45.8% once diagnosed. Conclusion: The prevalence rate of Ventriculostomy related infection is 25.8% at Tikur Annbessa Specialized Referral Hospital. The duration of external ventricular drain and Cerebrospinal fluid leak are identified risk factors. Ventriculostomy related infection is responsible for one third of mortality related with external ventricular drain. The remaining two third exact causes are not known.

Management and outcomes following emergency surgery for traumatic brain injury - A multi-centre, international, prospective cohort study (the Global Neurotrauma Outcomes Study).

INTRODUCTION: Traumatic brain injury (TBI) accounts for a significant amount of death and disability worldwide and the majority of this burden affects individuals in low-and-middle income countries. Despite this, considerable geographical differences have been reported in the care of TBI patients. On this background, we aim to provide a comprehensive international picture of the epidemiological characteristics, management and outcomes of patients undergoing emergency surgery for traumatic brain injury (TBI) worldwide. METHODS AND ANALYSIS: The Global Neurotrauma Outcomes Study (GNOS) is a multi-centre, international, prospective observational cohort study. Any unit performing emergency surgery for TBI worldwide will be eligible to participate. All TBI patients who receive emergency surgery in any given consecutive 30-day period beginning between 1st of November 2018 and 31st of December 2019 in a given participating unit will be included. Data will be collected via a secure online platform in anonymised form. The primary outcome measures for the study will be 14-day mortality (or survival to hospital discharge, whichever comes first). Final day of data collection for the primary outcome measure is February 13th. Secondary outcome measures include return to theatre and surgical site infection. ETHICS AND DISSEMINATION: This project will not affect clinical practice and has been classified as clinical audit following research ethics review. Access to source data will be made available to collaborators through national or international anonymised datasets on request and after review of the scientific validity of the proposed analysis by the central study team.

One Hundred Skull Base Meningiomas Operated at Black Lion Specialized Hospital, Addis Ababa, Ethiopia.

OBJECTIVE: After 10 years of training in their home country, neurosurgeons at Black Lion Specialized Hospital (Addis Ababa, Ethiopia) operated on skull base meningiomas independent of their external teachers. The present study used a retrospective design of an in-hospital series with short-term follow-up. METHODS: A total of 100 patients (mean age, 40.2 years; 80% women) had undergone surgery for skull base meningiomas from 2016 to 2017. Their symptoms included headache in 90%, impairment of vision in 47%, gait impairment in 25%, cognitive dysfunction in 29%, and seizures in 18%. Of the 100 tumors, 44% had a diameter >50 mm. Microsurgery was performed using the Hudson drill, Gigli saw, and conventional microsurgical instruments. RESULTS: A total of 59 complications in 39 patients occurred. Eleven patients had died within 3 months postoperatively. The cranial infection rate was 14%. The rate of Simpson grade I and II was 63%. We present the 3-12-month outcomes for 84 of the 100 patients. Of the 16 remaining patients, 4 were lost to follow-up (mean, 6.7 months) and 12 had died. Headache was noted in 65 of 74 patients preoperatively and in 20 during follow-up. Overall, 33 patients reported better vision, 48 reported similar vision, and 3 patients reported worse vision. Finally, 20 patients had gait difficulties preoperatively and 9 reported impaired gait during follow-up. CONCLUSION: A young faculty of neurosurgeons in a low income country was trained to perform neurosurgery for skull base meningiomas. The patients had presented at a young age with severe disabilities due to advanced disease. Surgery led to symptom improvement in a large proportion of patients; however, the complication and mortality rates were high.

Profile of Head Injuries: Prehospital Care, Diagnosis, and Severity in an Ethiopian Tertiary Hospital.

BACKGROUND: Consistent data on head injury is lacking especially in the low- and middle-income countries. Our study tries to characterize patients with head injury at the emergency department of one of the few tertiary public hospitals giving neurosurgical care in the country. METHODS: A retrospective cross-sectional study was performed from May 2015 to October 2015 in one of the neurosurgical teaching hospitals, Black Lion Specialized Hospital. All adult patients with head injury who visited the emergency department during the study period were included. Data on patients' sociodemographic, mechanism of trauma, clinical presentation, imaging findings, and presence of polytrauma were collected by a pretested questionnaire. The source of data was emergency department logbooks and patient charts. RESULTS: A total of 390 patients with head injury who visited the emergency department were included during the study period. There were 335 males (85.9%) and 55 females (14.1%) with the mean age (standard deviation) of 35.4 (15.6) years. Majority of patients came by taxi constituting 149 (38.2%) of all patients, whereas 147 patients (37.7%) used ambulance. Of 147 patients brought by ambulances, 133 (90.4%) were referred from other hospitals. The majority, 26 (45.6%), of patients who came directly to the emergency department used taxis. It is shown that the mode of arrival and origin of arrival are significantly related, P = 0.000. Mortality of severe head injury at the emergency department was 50.8%. CONCLUSIONS: Prehospital care coverage was low and ambulances were used mainly for interhospital transfers. Mortality of severe head injury at the emergency department is high and significantly associated with preventable causes like vital sign derangement.